This 2 part series was written by Jared Baylis, JoAnne Slinn, and Kevin Clark. 

Jared Baylis (@baylis_jared) is a PGY-4 and chief resident at the Interior Site of UBC’s Emergency Medicine residency program (@KelownaEM). He has an interest in simulation, medical education, and administration/leadership and is currently a simulation fellow through the Centre of Excellence for Simulation Education and Innovation in Vancouver, BC and a MMEd student through Dundee University.

JoAnne Slinn is a Registered Nurse, with a background in emergency nursing, and the simulation nurse educator at the Pritchard Simulation Centre in Kelowna. She recently completed her Masters of Nursing and has CNA certification in emergency nursing.

Kevin Clark (@KClarkEM) is the Site/Program Director for the UBC Emergency Medicine program in Kelowna. He completed a master’s degree in education with a focus on simulation back in the day when high fidelity simulation was new and sim fellowships weren’t yet a thing.

Welcome back to part 2 of our series on in situ simulation for quality improvement! Check out last months’ post for a deeper dive into the literature behind this concept. In this post, we will outline the vision, structure, participants, results, and lessons learned in the implementation of our ED in situ simulation program at Kelowna General Hospital (KGH).  

The Vision

KGH is a tertiary care community hospital serving the interior region of British Columbia.  Our emergency department (ED) sees in excess of 85,000 patient visits per year.  In 2013, we became a University of British Columbia distributed site for training Royal College emergency medicine residents. With this program came a responsibility to increase the academic activities in the department both for education and for team building and quality improvement (QI). Our aim with the program was:

1.     Improve interprofessional collaboration.
2.     Improve resuscitation team communication
3.     Develop resident resuscitation leadership skills.
4.     Educate emergency department professionals on medical expertise related to resuscitation.
5.     Identify and select two quality improvement action items that arise within each resuscitation scenario.
6.     Assess and respond to each QI action item in the interest of better patient care.
7.     Educate participants and other department staff with regards to each QI action item in an effort to change process and behaviors.

From a departmental QI standpoint, we applied the “SMART” framework; specific, measurable, attainable, realistic, and time based.¹ Our goal, as stated above, was to select two QI action items that came up during the debrief following our simulation. Our nurse educator group follows-up on each of these items and reports back to the local ED network, pharmacy, or the ED manager depending on which is seen as most appropriate for the particular QI issue. This ensures our model remains sustainable over time. Follow up emails are sent out to “close the loop” with attendees and department staff after each session. Learnings from the simulations are also presented to the local ED network to share with smaller sites that do not have simulation opportunities.

The Structure

Each session includes one to two scenarios where a “patient” with a critical illness is resuscitated by the team. Both adult and pediatric cases have been run using high fidelity simulators and a variety of resuscitation topics. The cases are run over a 90-minute time-period once per month immediately prior to our departmental meeting. This encourages attendance and participation. The timing of in situ simulation also coincides with our residency program’s academic day further increasing attendance and participation. The resuscitation/trauma room in the KGH ED is used for these sessions. The program has been well received and was highlighted on the local Global News Channel as a public display of our QI initiative.

The session begins with a pre-brief that includes brief introductions, general objectives, confidentiality, fidelity contract, and an outline for the session. This is followed by an orientation to the simulator, monitors, and equipment in the room. The scenario is then begun with a pre-hospital notification, bedside handover by paramedics, and then emergency department care ending with decision on disposition. The scenario is run in real time to maximize realism in terms of the time it takes to draw up and administer medications etc. This is followed by a debriefing session that takes in feedback from all team members as well as observers. This is led by a staff physician with experience in simulation debriefing. CanMEDS themes such as communication, collaboration, leadership and medical expertise are all discussed.²

Participants and Recruitment

Participants include emergency physicians, residents, nurses, respiratory therapists, pharmacists, paramedics, security, and students from the aforementioned groups. Participants are recruited with an email announcing the session one week prior, sign up lists on the educators’ door, and posters placed in the ambulance bay and paramedic stations. Cases are determined by the EM Residency Director in conjunction with the Simulation Fellow, ED Nurse Educators, and the Simulation Nurse Educator. The cases are distributed to the discipline leads 2-7 days prior to the session in order to prepare students and newer professionals that may be joining.

Our Results

There were a total of 65 participants when the program began in 2015, with an average of 16 participants/session. This grew to 130 total participants and an average of 19 participants/session in 2016. There was a further increase in 2017 to 213 total participants with a session average of 24 participants giving a total of 408 participants since program inception. The distribution of participant disciplines over the duration of the program is below:

Graph 1: ED In Situ Participant Data 2015 – 2017

Feedback has been informal, but overwhelmingly positive. The ED nurse educators have found in-situ simulation to be one of the most valuable educational experiences for the department and have advocated for the sessions to be paid education time for the nurses. This has increased buy-in and participation. Paramedics have commented that it is time well spent, that they appreciate seeing what happens to the patient after they hand over care. They also remarked that this type of training will go a long way towards better inter-agency cooperation and understanding.

A variety of QI initiatives have been brought forward from these sessions. This has included better use of existing protocols, finding equipment that is poorly placed or expired, and determining better team-working processes similar to what was described in our literature review. One specific example of our QI initiatives was the development of a simulation case around our pediatric diabetic ketoacidosis protocol (that was still in draft form), running the case using the protocol, and then providing feedback on revisions including clarity on initial fluid replacement orders, additions to the initial blood work orders, and improvements to insulin pump delivery. Further QI initiatives that have resulted from this project are summarized below.

Table 2: QI action items and their resulting actions

CATEGORY	ACTION
Team/Communication 1.     Delay in call for help 2.     Team members not speaking up when change in patient condition noticed 3.     Medication order confusion between physician, pharmacy, and nursing 4.     Not all team members hearing report from paramedics	1.     Reinforce calling for help early 2.     Fostering an environment that encourages input from all team members 3.     Reinforce importance of using closed-loop communication with medication orders 4.     Reinforce one paramedic report where everyone stops and listens (unless actively involved in CPR)
Equipment/Resources 1.     Difficulty in looking up medication information in resus. bay 2.     Unsafe needles for use with agitated patients in resus bay 3.     Expired Blakemore tubes in ED 4.     Unsure of PPE needed during potential Carfentanil exposure case	1.     Installed additional computer in resus. bay in order to better access information 2.     Auto-retractable needles made available in resus. bay 3.     New Blakemore tubes ordered 4.     Communicated the provincial Medical Health Officer recommendations for Carfentanil PPE to staff
Knowledge/Task 1.     Lack of knowledge of local use of DOAC antidote 2.     Uncertain of local process for initiating ECMO in ED 3.     Conflict over when to intubate a hemodynamically unstable patient	1.     Reviewed indications/contraindications, ordering information, and administration of Praxbind (idarucizumab) 2.     Reviewed team placement, patient transfer, and initiation of ECMO line in ED 3.     Reinforced resuscitation prior to intubation
PPE – Personal Protective Equipment DOAC – Direct-Acting Oral Anticoagulants ECMO – Extracorporeal Membrane Oxygenation

Successes, Lessons Learned, and Suggestions

In this article, we set out to describe our experience with regard to ED based in situ simulation as well as to outline the evidence for in situ simulation as a QI tool (part 1). We hope that this serves as encouragement to those of you who are thinking of getting such a program started at your institution. In reflecting on our process, we would offer these suggestions and lessons learned:

1. Engage a team. It takes a team that is committed to the process to get this off the ground. Take the evidence to your team, gain support, and then begin your program.
2. Start out with your goals/aims/objectives in mind so that you know what it is you’re trying to accomplish.
3. “Buy in” is key. Try to structure your program so that it is convenient and so that attendance and participation is encouraged. For us this meant holding our in situ simulation on academic days for the residency program and immediately preceding our departmental meeting.
4. Celebrate your successes with everyone involved to build a culture that values in situ simulation and quality improvement.
5. Bring team members on board who are trained and experienced in simulation as debriefing a multidisciplinary simulation can introduce specific challenges. This is beyond the scope of this article but there are many good resources out there on debriefing including the PEARLS framework.³

We’ll close with the 10 tips that Spurr et al. described in their excellent article on how to get started on in situ simulation in an ED or critical care setting.

1. Think about your location and equipment    
2. Engage departmental leaders to support simulation
3. Agree on your learning objectives for participants and the department
4. Be a multiprofessional simulation program
5. Strive for realism
6. Start simple, then get complex
7. Ensure everyone knows the rules and feels safe
8. Link what you find in simulation to your clinical governance system
9. The debrief is important: be careful, skillful, and safe
10. Be mindful of real patient safety and perception

We would love to hear from you. If you have any questions or comments please feel free to comment on this post or to reach us by twitter (@baylis_jared, @KClarkEM, @KelownaEM).

References:

1. Haughey D. Smart Goals [Internet]. [cited Dec 2017]. https://www.projectsmart.co.uk/smart-goals.php
2. CanMEDS: Better standards, better physicians, better care [Internet]. [cited Dec 2017]. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
3. Eppich W, Cheng A. Promoting excellence and reflective learning in simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare. 2015 Apr 1;10(2):106-15.
4. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+ 1) tips to get started with in situ simulation in emergency and critical care departments. Emerg Med J. 2016 Jul 1;33(7):514-6.